UltraField2899
The nurse is caring for a client who is receiving external…
The nurse is caring for a client who is receiving external radiation therapy for metastatic carcinoma of the breast. Which of the following precautions should the nurse take when
caring for the client?
Wear gloves when emptying the clients emesis basin
Wear a protective down when assisting the client with a bed bath
Use time and distance limitations while at the client’s bedside
Use a film badge to monitor radiation exposure while in the client’s room
The nurse enters the room of a client who is experiencing the cardiac rhvthm shown in the electrocardiogram (ECG) strip below. The client is unresponsive, pulseless and apneic. Which of the following actions should the nurse take? Select all that apply
Alert the emergency response team.
Contact the client’s primary health care provider.
Review laws regarding do not resuscitate (DR) orders for the geographical jurisdiction.
Determine desired interventions from the familv members
Initiate cardiopulmonary resuscitation (CPR).
The nurse is caring for a client with major depression who has been involuntarily admitted to a psychiatric unit. Which of the following statements by the client would indicate a correct understanding of the client’s rights?
01.I understand my employer can obtain information about my hospitalization because I have been involuntarily admitted to this facility.”
02 I cannot exercise the right to vote in the upcoming election because I have been involuntarily admitted to the facility.”
?3.I will be required to have a guardian appointed to manage my finances while I am in the facility.’
04. “I have the right to refuse prescribed medications while I am in the facility.”
The nurse is talking with a client who is competent and has end-stage renal disease (ESRD). The client states, “I do not wish to be resuscitated in the event of an emergency.” The nurse notifies the primary health care provider of the client’s wish. Which of the following ethical principles is the nurse supporting?
paternalism
autonomy
veracity
justice
The home-health nurse is visiting a client who had hip replacement surgery 3 days ago. The client lives alone and has limited mobility and financial resources. Which of the following actions by the nurse would best reflect the principle of advocacy?
01.assisting the client to bathe
02.teaching the client exercises for increasing strength and flexibility
03.contacting a community service organization to arrange meal delivery for the client
04.ensuring that the client’s medications are within the client’s reach before leaving the home
The nurse is reinforcing teaching with a client who had a colon resection 2 days ago. Which of the following information should the nurse reinforce?
01. You should avoid placing a pillow over your incision to cough and deep-breathe.”
02 Your closed-wound drainage system should hang free to promote gravity drainage.”
03 Your digestive system is not ready for the food your family has brought for you to eat.”
04. You may sit with your legs in a dependent position to prevent deep vein thrombosis (DVT).”
The nurse is teaching the parents of a 14-year-old client newly diagnosed with asthma about possible asthma triggers. Which of the following should the nurse include? Select all that apply
flashing lights and sleep deprivation
food additives and exercise
caffeine intake and hunger
fragrances and smoke
stress and emotions
The nurse is caring for a client with hyperparathyroidism. Which of the following findings would the nurse expect to observe?
dry skin
hair loss
bone pain
brittle nails
The nurse is caring for a client who has pernicious anemia. The nurse should understand that the client’s condition will most likely result in a deficiency of
01folic acid
02 thiamine (vitamin B1)
03. cobalamin (vitamin B12)
04.iron
The nurse is reviewing laboratory test results for a client who has just received a unit of fresh frozen plasma. It would indicate that the treatment regimen has been effective if the client experiences a decreased
platelet count
hemoglobin (Hgb)
white blood cell (WBC) count
activated partial thromboplastin time (APTT)
The nurse is caring for a client with schizophrenia. The client is rapidly pacing, clenching the fists and mumbling profanities. Which of the following actions should the nurse take?
Ask if the client is hearing voices.
Tell the client to go to the client’s room and rest quietly.
Place an arm gently around the client’s shoulders, and walk with the client.
Request that members of the security team come to the unit and surround the client.
The nurse has attended a staff education program about toilet training of toddlers. Which of the following findings should the nurse recognize as an indication for readiness to toilet train? Select all that apply
has a wet diaper after waking up from a nap
fusses when sitting on the toilet for 5 minutes is impatient when a diaper is soiled
lacks curiosity about adults’ toilet habits
removes clothing and walks around the room
The nurse is contributing to a staff education program about incident reports. Which of the following should the nurse suggest including as an example of an occurrence that would require completion of an incident report? Select all that apply.
medication errors
needle-stick injuries
client who fell in the hall
client who experienced a seizure
client who refused all prescribed medications
The nurse from a medical-surgical unit is temporarily assigned to a maternity unit. It would be most appropriate to assign the medical-surgical nurse to a client who had a
cesarean delivery 24 hours ago
third-degree perineal laceration during delivery
premature rupture of membranes (PROM) and is on bed rest
vaginal delivery 2 days ago and is scheduled to be discharged
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is expectorating mucopurulent sputum. Which of the following infection control precautions should the nurse implement? Select all that apply.
Place the client in a room with monitored negative air pressure.
Wear a particulate respirator mask (N95) when taking the client’s vital signs.
Wear clean gloves when assisting the client to remove the soiled gown.
Remove the gloves before leaving the client’s room.
Clean the reusable blood pressure cuff before taking the client’s blood pressure.
The nurse is preparing to report a change in condition to a client’s primary health care provider. Which of the following information should the nurse include? Select all that apply.
01 vital signs
02. laboratory test results
03 complete medical history
04 medications administered
05. physical assessment findings
The nurse has received the following information about assigned clients. The nurse should first assess the client
01 with ulcerative colitis who is reporting having 4 loose, blood-streaked stools in the past 3 hours
02. with an intestinal obstruction who has a nasogastric (NG) tube attached to intermittent suction and is reporting abdominal pain
03 who had transurethral resection of the prostate (TURP) 1 day ago, has an indwelling urethral catheter and is reporting occasional bladder spasms
04who had a right lung lobectomy 2 days ago, has a chest tube and fluctuations in the water-seal chamber of the closed-chest drainage system
The nurse has reinforced teaching with a client who is at 10 weeks gestation and is scheduled for a transvaginal ultrasound. Which of the following statements by the client would indicate a correct understanding of the teaching?
“I understand that there is a small risk of harm to the fetus from radiation exposure during the test.”
“The transvaginal approach provides less detailed results than an abdominal approach.
*The test will help determine whether I have enough amniotic fluid.
“The test will determine whether my baby’s heart is beating.
The nurse is planning a staff education program about informed consent. Which of the following information should the nurse include?
01 Nurses should obtain consent from the client’s spouse when the client is seeking care in the emergency department (ED).”
02 Clients with severe Alzheimer’s disease (AD) may not be able to give consent for treatment.”
03 It is the nurse’s responsibility to explain the procedure for a second time if the client has questions about the procedure.”
04. “Nurses should verify the client’s understanding of the procedure by asking the client to repeat the information verbatim.
The nurse is planning a staff education program about informed consent. Which of the following information should the nurse include?
“Nurses should obtain consent from the client’s spouse when the client is seeking care in the emergency department (ED).”
“Clients with severe Alzheimer’s disease (AD) may not be able to give consent for treatment.”
It is the nurse’s responsibility to explain the procedure for a second time if the client has questions about the procedure.”
“Nurses should verify the client’s understanding of the procedure by asking the client to repeat the information verbatim.”
The nurse has attended a staff education program about child abuse. Which of the following factors may contribute to child abuse? Select all that apply.
1. a parent who was a victim of child abuse
2. a child who is disabled
3. a parent with a history of substance abuse
4. a child who is hyperactive
5. a child born after 37 weeks gestation a parent who exhibits high self-esteem
The home-health nurse is teaching a client who is newly diagnosed with diabetes mellitus (type 1) about insulin therapy. Which of the following information should the nurse include?
“Rotation of injection sites within 1 anatomic site is the preferred method.”
“Rapid-acting insulin should be administered 15 minutes after meals.”
3. The intramuscular route is preferred for insulin administration.”
4. “For faster absorption, inject insulin into your thigh.”
The nurse in the emergency department (ED) is caring for a 4-year-old client who has a fractured arm and bruises in various stages of healing on the trunk. The nuse observes that the parents of the client never leave the examination room. Which of the following actions would be a priority for the nurse to take?
Document the nurse’s interpretation of the family dynamics in the client’s medical record.
Notify the nursing supervisor of the findings.
Kneel to be at eye level with the client, and state, “You are safe now.”
Ask the client, “Has your mommy or daddy hurt you?”
The nurse is caring for a client who is receiving external radiation therapy for metastatic carcinoma of the breast. Which of the following precautions should the nurse take when caring for the client?
Wear gloves when emptying the client’s emesis basin.
Wear a protective gown when assisting the client with a bed bath.
Use time and distance limitations while at the client’s bedside.
Use a film badge to monitor radiation exposure while in the client’s room.
The nurse is caring for a client who is receiving external radiation therapy for metastatic carcinoma of the breast. Which of the following precautions should the nurse take when caring for the client?
01Wear gloves when emptying the client’s emesis basin.
02. Wear a protective gown when assisting the client with a bed bath.
03.Use time and distance limitations while at the client’s bedside.
04. Use a film badge to monitor radiation exposure while in the client’s room
The nurse is providing care for a client with peripheral arterial insufficiency. Which of the following nursing interventions would promote circulation?
maintaining the client’s extremities in an elevated position
keeping the client’s extremities warm
03 Llimiting the amount of ambulation the client is allowed
04 reducing the amount of foods containing vitamin K in the client’s diet
The nurse is teaching a client with hepatitis A (HAV). Which of the following instructions should the nurse include?
“Drink bottled water rather than tap water.”
“Maintain a low-carbohydrate, low-calorie diet.”
3. Avoid drinking beverages containing caffeine.”
4. “Eat small, frequent meals throughout the day.”
The nurse is preparing to administer the hepatitis B vaccine to a client. The nurse should understand that the vaccine is administered
orally.
intranasally
subcutaneously
intramuscularly
The nurse has inserted an indwelling urethral catheter for a female client and determines that the catheter has gone into the client’s vagina. Which of the following actions should the nurse take first?
Clean the urinary meatus again.
Leave the catheter in the client’s vagina.
Remove the catheter from the client’s vagina.
Attempt to reinsert another sterile catheter into the meatus.
The nurse has inserted an indwelling urethral catheter for a female client and determines that the catheter has gone into the client’s vagina. Which of the following actions should the nurse take first?
01. Clean the urinary meatus again.
02. Leave the catheter in the client’s vagina.
03. Remove the catheter from the client’s vagina.
04.Attempt to reinsert another sterile catheter into the meatus.
The nurse is caring for a client who had a left below-the-knee amputation (BKA) 3 days ago. The client states, “I am worthless. I cannot even dress myself.” Which of the following actions should the nurse take? Select all that apply.
Provide opportunities to discuss altered appearance and self-worth
Reassure the client that everything will be all right.
Assist the client with identifying personal strengths and attainable goals
Suggest that the client talk about a more positive topic.
Initiate a referral to an occupational therapist.
The nurse is caring for a client who is receiving heparin for pulmonary emboli. Which of the following laboratory tests should the nurse monitor to assist with evaluating the effectiveness of heparin therapy?
prothrombin time (PT)
complete blood count (CBC)
fibrinogen degradation products
activated partial thromboplastin time (APTT)
The nurse is reinforcing teaching about car safety with a group of parents. Which of the following information should the nurse reinforce? Select all that apply.
1. “Toddlers should ride in a forward-facing car seat once they meet the manufacturer’s height and weight recommendations.”
2. “Children younger than 13 years should not ride in the front seat of cars with airbags.”
The rear doors of the car should remain unlocked while the car is in motion.”
Children should continue to ride in a booster seat until they are tall enough to properly wear the seat lap and shoulder belt.”
Toddlers should be restrained in a car seat with a 2-point harness.”
The nurse is caring for a client who has fever, chills, nuchal rigidity and a petechial rash. Which of the following infection control precautions should the nurse implement?
01. Place the client in a private room with monitored negative air pressure.
02.Wear a surgical mask when administering prescribed medications to the client.
03.Wear a protective gown when obtaining the client’s vital signs.
04.Place a stethoscope in the client’s room to be used for that client only.
The nurse is collecting data from a 15-year-old client. Which of the following statements by the client would be essential to follow up?
01. “I eat lunch at a fast-food restaurant with my friends every day.”
02″I need to shower every day and use deodorant to reduce body odor.”
03.”I need to set an alarm to wake up in the morning because I like to stay up late at night.”
04. “I received 3 doses of the human papillomavirus vaccine when I was 12 years old.”
The nurse is collecting data from a 15-year-old client. Which of the following statements by the client would be essential to follow up?
“I eat lunch at a fast-food restaurant with my friends every day.”
“I need to shower every day and use deodorant to reduce body odor.”
3 “I need to set an alarm to wake up in the morning because I like to stay up late at night.”
4 “I received 3 doses of the human papillomavirus (HPV) vaccine when I was 12 years old.”
The nurse is caring for a client who has been diagnosed with the food-borne illness trichinosis. The client, after obtaining some relief from vomiting and diarrhea, asks the nurse, “What did I eat that made me so ill?” Which of the following food items recently consumed by the client should the nurse reinforce as being responsible for the parasitic infection?
tuna salad
pork chops
egg salad
unpasteurized milk
The nurse is monitoring the intravenous infusion for a pediatric client who has an order for 5% dextrose in 0.2% sodium chloride (quarter-strength saline), IV, 100 ml/kg/day. The client weighs 4.5 kg (10 lb). How many m/hr should the nurse ensure is programmed in the electronic infusion pump? Record your answer using 1 decimal place.
The nurse is providing an education program for family members of clients with schizophrenia. Which of the following information should the nurse include?
01. “Avoid asking the client about suicidal thoughts or plans in order to prevent the client from having suicidal ideation.”
02 “Suggest that the client spend quiet time alone when the client is experiencing hallucinations.
03 “Compliance with the medication treatment plan is vital for the prevention of relapse.”
04 “Confront delusional thinking when the client is having delusional thoughts.”
The nurse is assessing a client with Addison’s disease. Which of the following findings would support a diagnosis of Addison’s disease?
tachycardia
hypertension
exophthalmos
hyperglycemia
The nurse is caring for a client who has the skin condition shown below. Which of the following complications is the client at risk of developing?
neuralgia
glomerulonephritis
gangrene
cellulitis
The nurse manager is developing a unit-based quality improvement program. Which of the following would be the most effective action for the manager to take?
Appoint a staff member as the client safety officer for the unit.
Create a quality improvement committee that includes staff members
Ask the facility’s risk management department to suggest improvements for the unit.
Incorporate incident reports involving staff members into the staff members’ performance reviews.
The nurse is conducting a health screening for clients who are at risk for hepatitis B (HBV). The client at risk for developing HBV
01. drinks 2 alcoholic beverages daily
02. has a family history of hepatic cirrhosis
03. is receiving hemodialysis treatments
04. has an increased alanine aminotransferase (ALT)
The nurse has attended a staff education program about hospice care. Which of the following statements by the nurse would require follow-up?
*Hospice care ends when the client dies.”
“The goal of hospice care is to help clients to have a peaceful and dignified death.”
03 .Hospice care can be provided for clients in the home, the hospital or a nursing home-based unit.”
04 A team of professionals and nonprofessionals provides hospice care services for clients to ensure a full range of care services.”
The nurse is teaching participants at a health fair about preventing gastric cancer. Which of the following instructions would be appropriate for the nurse to include?
1. “Increase the amount of folic acid in your diet.”
2. “Decrease the amount of iron in your diet.”
3. “Enroll in a smoking-cessation program.”
4. “Develop a stress-reduction program.”
The nurse is planning discharge teaching for a client who had abdominal surgery 5 days ago. Which of the following information should the nurse include? Select all that apply.
“Notify the surgeon if your pain increases.”
“You can drive yourself to the first follow-up visit with the surgeon.”
“Resume activities of daily living (ADL) slowly over a period of time.”
“You should stop taking the prescribed antibiotic when the swelling around the surgical incision is gone.”
“You will need to increase your daily consumption of protein and vitamin C while the surgical wound is healing.”
